Lateral view

The lateral view offers important information on tip projection; nasal length; dorsal profile or contour, including the tip-supratip relationship; and alar-columellar relationship. The nasal tip ideally should project strongly from the face and lead gracefully to the supratip dorsum, creating a modest supratip break. An identifiable, but not overly exaggerated, columellar double break typically marks the junction of the medial and intermediate crus. Nasal tip projection is assessed consistently using the method described by Goode [16,17]. If the length of a line drawn from the tip-defin-ing point perpendicular to a tangent to the alar-facial junction is greater than 0.55 to 0.60 of the line drawn from the nasion to tip-defining point, the nose may be overprojected. When assessing tip projection, relationships between the nose and other esthetic facial features (eg, chin projection, forehead contour, ethnic background) must be considered.

Nasal length is complicated to define. The objective definition of nasal length is the vertical distance from the nasion to the tip-defining point, and this measurement is compared with the other horizontal thirds of the face and the overall stature of the patient to determine if the nose is of appropriate length. The factors contributing to the appearance of nasal length are significantly more complex, however. The nose can be considered to have three lengths, with nasion to tip being the central length and nasion to alar margin being the lateral lengths. A short or long lateral length may reflect a retracted or hooded ala, whereas a short or long central length may reflect an obtuse or acute nasolabial (columellar-labial) angle. A deep nasofrontal angle contributes to the illusion of a short nose, and a shallow nasofrontal angle adds apparent length to the nose [18].

The nature of the columellar-labial confluence and columellar-lobular angle (double break) also must be assessed. Webbing or tenting of the columel-lar-labial confluence should be noted. An overly obtuse columellar-labial angle or an exaggerated double break makes the nose appear short, whereas the converse (acute columellar-labial angle or absent double break) adds apparent length. A posteriorly inclining lip or deficiency of the premaxilla may confound accurate measurement of the columellar-labial angle. Also, the relationship of the nose to other facial structures influences nasal length; a flat forehead gives the illusion of increased nasal length [18].

One should be familiar with the esthetic angles applied in facial analysis as general guidelines for standards of facial esthetics and facial harmony. The Powell and Humphries esthetic triangle (nasofacial, nasofrontal, nasomental, and mentocervical angles) and the nasolabial angle or confluence are a few of the more commonly cited measurements.

Assessment of the dorsal contour should identify any concavity, convexity, or irregularity. A high dorsum with a slight concavity at the rhinion generally is considered the esthetic ideal in the nose of a white woman. A high dorsum that is straight or with a small hump is ideal in a white man. Other notable components of the dorsum include the nasal starting point, which ideally is positioned at the level of the superior palpebral fold, and the tip-supratip relationship as previously mentioned.

The ala is analyzed in detail on the lateral view. Insertion of the ala on the face 2 to 3 mm above the columella in the horizontal plane as described by Crumley and Lanser [13] is judged to be normal. The contour of the alar rim in profile ideally approximates a "lazy S" shapedone should note if this is normal, exaggerated, or straight. The size of the alar lobule is classified as small, normal, or large. The alar-columellar relationship should be described precisely. The range of normal columellar show generally is considered to be 2 to 4 mm. The complexities of the alar-columellar relationship were categorized by Gunter et al [19] , who identified abnormal positioning of the ala and the columella in relationship to a line drawn through the long axis of the nostril. All patients have a hanging, normal, or retracted ala and a hanging, normal, or retracted columella. The alar-columellar relationship comprises nine possible anatomic combinations.

On lateral view, the long axis of the nostril should rise at approximately 10 to 30 from a plane horizontal to the Frankfurt plane. This is a reliable determinant of the need for operative rotation of the nasal tip [12].

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